urologists are biased about the treatment of prostate cancer…but not like you’d think.

Fat…the mud of surgery.

When I was a resident in urology at the V.A. in Augusta, Georgia I had done a biopsy on a patient that showed cancer. The patient was sitting on an exam table as I stepped out to make my case to the attending physician to do a radical prostatectomy on him. The patient fit all the criteria for surgery save one thing. He was very much over weight and carried all of it right over where you’d make the incision (a vertical suprapubic incision.) So…I make my case and the attending wants to meet and interview the patient. I open the door with the attending behind me and we both are met with the side view silhouette of the patient prominently displaying his large belly. Before I can speak or introduce the attending, he reaches around me and pulls the door closed. Out in the hall outside the patients exam room the attending says to me matter of factly,” No way in hell John.” And then walked away.

Comments made about my book are interesting to me. One was recently placed on Amazon and the author rated my book as a 3 (good but not great). The complaint had to do with his feeling that I was biased toward surgery. The review was actually quite good and thorough and it was obvious that he was an informed patient. I am impressed by what I have read by men who really have researched this disease, as you have seen just last week one person corrected an error I made in regards to PIN. I had used the wrong word for the I. ( I remembered it as intranuclear and it was actually intraepithelial.)

So…Am I as a urologist biased toward surgery? Several points and this will also give you some insight in the mind of a surgeon in general and a urologist in particular.

• In my book I said that I was biased toward surgery but only in certain circumstances. I chose surgery because of my age, my biopsy specifics , the fact that I knew the potential complications and was at peace with that, and that I feel it is a “cleaner” treatment. Now…that’s for me.
• I don’t think surgery is a good option for someone with a phobia about incontinence.
• Not good if you have other medical problems that are moderately severe.
• If you are overweight with a protuberant abdomen- (the robot somewhat neutralizes this concern)
• If you can’t miss work.
• If you have a family member that needs you to be of help to them.
• Your life expectancy is less than what we would anticipate from the specifics of your prostate biopsy.
• You don’t want surgery.
• You have very favorable parameters and want to the best treatment with least down time.
• If you are over 75  I wouldn’t recommend surgery.
• If you are over 65 and in poor health.

This will sound tricky but in the very best scenario no complications (can’t guarantee that) and alls well after the treatment and you compare the treatments….I feel surgery is better. Why? No cancer, no incontinence, no impotence…both the same right, both equal?

Well…the radiation guy has radiation in his body and this comes with consequences down the road. Other surgeries, other potential cancers from the radiation. Patients forget (or not told or did not hear) that the side effects of radiation occur sometimes years after it is given. Or the options of intrabdominal surgery may be hampered by having had radiation. All of these issues however don’t matter if you are not a candidate for surgery, you don’t want surgery, and you value the fact that you’d rather have irritative voiding symptoms of radiation than the potential stress incontinence symptoms of surgery.

So I am biased for surgery if you are the right patient, with the right path report, and the right frame of mind.

I am not biased for surgery if you are not the right candidate, if you don’t want it or if “you” are biased against surgery.

My job is to state the facts as I see them and aid my patients to the decision which they feel is best for them.

As to the review and being graded low for speaking more to the side effects of radiation than to surgery…here’s the deal on that.

Most patients know very well the risks with surgery. They don’t however know as well the short and long-term side effects of radiation. I do believe I did spent a lot of time on this issue…particularly as it pertains to how one voids after radiation if they had an enlarged prostate before the radiation.

As a radiation therapist friend of my told me about the options about treatments, “John there ain’t no free ride.” The trick is matching the patient to the disease and the treatment.